To Örebro University

BACKGROUND: Prehabilitation promotes postoperative recovery through preoperative optimisation; however, few studies have been conducted under real-world conditions. Our objective was to determine the extent to which a multimodal prehabilitation programme influenced intermediate and late recovery post-colorectal surgery in a type 1 effectiveness-implementation and randomised pragmatic trial. We hypothesised that a prehabilitation class, as part of an Enhanced Recovery After Surgery (ERAS) pathway, would reduce length of hospital stay (LOS).

METHODS: Adult male and female patients with colorectal disease requiring an elective primary resection at a single centre were randomised to the intervention or standard care group at least 2 weeks before surgery. All participants attended an ERAS class, which was extended to include prehabilitation components of nutrition education, supplements, walking with a smartwatch, functional exercises, and deep breathing in the intervention group. Effectiveness outcomes included LOS (primary) and 6-min walking distance (6MWD; secondary outcome) at 6 weeks post-surgery. Implementation outcomes included adherence to prescribed step count and nutrient intakes. Multivariable regression analyses were adjusted for age, sex, type of surgery, and COVID-19.

RESULTS: The study ended prematurely. In total, 110 patients were included. Two-thirds had cancer and mean prehabilitation duration was 17.2 (sd 5.5) days. LOS was not different between groups. Preoperative median step count did not differ between groups, but protein inadequacy (prevalence ratio: 0.59 [95% CI: 0.36-0.82]) decreased substantially with prehabilitation. After surgery, the mean difference in 6MWD was +38 m (95% CI: 9-67 m) for prehabilitation vs control, indicating earlier functional recovery.

CONCLUSIONS: A pragmatic prehabilitation programme did not influence length of hospital stay (underpowered because of early trial termination), but did reduce preoperative protein inadequacy (implementation outcome) and improve early functional recovery (secondary outcome).

CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov (NCT04247776).

Early oral feeding is the preferred mode of nutrition for surgical patients. Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition and underfeeding are risk factors for postoperative complications, nutritional therapy is mandatory for any surgical patient at nutritional risk, especially for those undergoing upper gastrointestinal surgery. The focus of this guideline is to cover nutritional aspects of the Enhanced Recovery After Surgery (ERAS) concept and the special nutritional needs of patients undergoing major surgery, e.g. for cancer, and of those developing severe complications despite best perioperative care. From a metabolic and nutritional point of view, the key aspects of perioperative care include: a) Integration of nutrition into the overall management of the patient, b) avoidance of long periods of preoperative fasting c) re-establishment of oral feeding as early as possible after surgery d) start of nutritional therapy early, as soon as a nutritional risk becomes apparent e) metabolic control e.g. of blood glucose, f) reduction of factors which exacerbate stress-related catabolism or impair gastrointestinal function, g) minimized time on paralytic agents in the postoperative period, and h) early mobilization to facilitate protein synthesis and muscle function. The guideline presents 44 recommendations for clinical practice in patients undergoing elective and non-elective surgery, including new recommendations for frailty assessment, sarcopenia diagnosis, and prehabilitation. As in the former ESPEN practical guideline, the recommendations were additonally presented in decision-making flowcharts.

BACKGROUND: Patients hospitalized with moderately severe or acute severe ulcerative colitis (UC) may experience metabolic disturbances, including alterations in insulin resistance due to inflammation and the administration of glucocorticoids (GCs). This pilot study aimed to evaluate insulin sensitivity in patients hospitalized for moderately severe to severe UC.

METHOD: Patients hospitalized for moderately-severely active UC at Örebro University Hospital, Sweden, were eligible for inclusion. Quantification of insulin sensitivity was performed using the hyperinsulinemic euglycemic clamp (HEC) methodology. Assessment of insulin sensitivity was performed during both the index flare and while patients were in steroid-free clinical, biochemical and endoscopic remission during follow-up. Additionally, healthy controls were evaluated using HEC for comparison.

RESULTS: Five patients with moderately-severely active UC, treated with intravenous GCs for ≥2 days, were included and underwent HEC assessment. During the index flare, four patients received second-line treatment with infliximab due to non-response to GC, and one patient was subsequently referred for acute subtotal colectomy. At inclusion, all five patients exhibited significantly reduced insulin sensitivity, and levels appeared similar regardless of the outcome of the index flare. At remission during follow-up, the insulin sensitivity was restored to levels comparable to healthy controls (n = 5).

CONCLUSION: The study demonstrates that patients with moderately severe to severe UC experience significant insulin resistance, irrespective of the outcome of the flare. The reduced insulin sensitivity is likely driven by a combination of active inflammation and GC treatment, as insulin sensitivity returned to normal levels when patients achieved remission during follow-up.

BACKGROUND: The growing proportion of older individuals worldwide is anticipated to lead to an increase in the number of elderly patients requiring surgery for colon cancer. Consequently, it is crucial to identify specific risk factors for mortality and complications after colon surgery in this age group.

METHODS: The Swedish part of the ERAS registry (EIAS) between 2009 and 2022 was used. Patients aged ≥ 75 years undergoing colon surgery were compared with younger patients regarding risk factors for severe complications and mortality after multivariate regression analysis.

RESULTS: After adjusting for potential confounders, three risk factors specifically associated with severe complications in elderly patients were identified: severe pulmonary disease (OR 1.64; 95% CI 1.04-2.58), recent immunosuppressive treatment (OR 1.92; 95% CI 1.12-3.30), and left hemicolectomy (OR 1.43; 95% CI 1.04-1.97). Furthermore, four risk factors for mortality, statistically significant only in the older age group, were found: male sex (OR 1.73; 95% CI 1.08-2.76), ASA ≥ 3 (OR 2.92; 95% CI 1.66-5.15), severe pulmonary disease (OR 2.28; 95% CI 1.02-5.06), and open surgery (OR 1.68; 95% CI 1.04-2.73).

CONCLUSION: Several risk factors for severe complications and 30-day mortality specific to the elderly group were identified. Among these, severe pulmonary disease was associated with both severe complications and mortality.

BACKGROUND: As perioperative care shifts to a more patient-centered model, understanding needs and experiences of patients is vital. Gaining such insight can enhance the alignment of care with patient priorities, encouraging adherence to recovery-oriented interventions. We aimed to explore patient-defined recovery and the elements that modify the recovery process for patients with colorectal disease under Enhanced Recovery After Surgery (ERAS) care.

STUDY DESIGN: A qualitative study was conducted at an ERAS-participating hospital in Alberta, Canada, between April 2018 to June 2019. A co-design focus group set the research direction and semi-structured interviews were conducted postoperatively in hospital or within 3 months post-discharge. Diverse patient ages and colorectal conditions were targeted through purposive sampling. Interviews were transcribed verbatim and analyzed through manifest and latent content analysis.

RESULTS: Twenty patients with mean age 62 (SD:13) years and 45% with cancer (n=17 interview, n=2 focus group and interview, n=1 focus group only) were enrolled. Recovery was defined by patients as the return to normal routines and four themes were identified. First, Phases of recovery: recovery was described as multidimensional phases distinctively as early, late/long-term, and the endpoint. Second, Recovery facilitators: recovery was supported through positive mindsets, conscious recovery, and taking an active role. Third, Recovery barriers: recovery was hindered by negative mindsets and treatment side-effects. Finally, Recovery catalysts: communication, autonomy, and expectations facilitated active or passive recovery.

CONCLUSION: Our patient-oriented recovery model may contribute a new dimension to the ERAS framework by capturing patients' recovery experiences. Further research is encouraged to explore its value in enhancing patient-centered care within ERAS.

Malnutrition is prevalent among surgical candidates and associated with adverse outcomes. Despite being potentially modifiable, malnutrition risk screening is not a standard preoperative practice. We conducted a cross-sectional survey to understand healthcare professionals' (HCP) opinions and barriers regarding screening and treatment of malnutrition. HCPs working with adult surgical patients in Canada were invited to complete an online survey. Barriers to preoperative malnutrition screening were assessed using the Capability Opportunity Motivation-Behaviour model. Quantitative data were analyzed using descriptive statistics and qualitative data were analyzed using summative content analysis. Of the 225 HCPs surveyed (n=111 dietitians, n=72 physicians, n=42 allied healthcare professionals), 96%-100% agreed that preoperative malnutrition is a modifiable risk factor associated with worse surgical outcomes and is a treatment priority. Yet, 65% (n=142/220; dietitians: 88% vs. physicians: 40%) reported screening for malnutrition, mostly in the postoperative period (n=117) by dietitians (n=94), and just 42% (48/113) of non-dietitian respondents referred positively screened patients to a dietitian for further assessment and treatment. The most prevalent barriers for malnutrition screening were related to opportunity, including availability of resources (57%, n=121/212), time (40%, n=84/212) and support from others (38%, n=80/212). In conclusion, there is a gap between opinion and practice among surgical HCPs pertaining to malnutrition. Although HCPs agreed malnutrition is a surgical priority, the opportunity to screen for nutrition risk was a great barrier.